AVOIDING THE WORD “CANCER” when talking to patients about their low-grade, localized prostate cancer may convince more men—at least 100 000 each year—to consider delaying immediate treatment in favor of active surveillance, recommended an independent panel convened in December by the National Institutes of Health. Although the experts’ state-of-thescience statement did not suggest a less anxiety-provokingterm,itstronglycalled for better ways for physicians to counsel patients about active monitoring, which issometimespresentedtopatientsas“doingnothing.”Primarycarephysicians in particular“couldset thestage forsurveillancetobeanalternative[tocurativetreatment] if the patient chooses to be screened” forprostate cancer, saidPatricia Ganz, MD, the panel chair and director of the Division of Cancer Prevention andControlResearchat theUniversityof California in Los Angeles. The panel defined low-risk prostate cancer as having a prostate-specific antigen (PSA) level of less than 10 ng/ mL and a Gleason score of 6 or less. But only 10 percent of men with low-grade prostate cancers currently agree to surveillance; of those who do elect observation, about a quarter will receive curative therapy (prostatectomy or radiation therapy) in 2 to 3 years and half will be treated in 5 years for reasons that are unclear, said the panel. For elderly menwithhigher-riskprostatecancerand men with very low PSA levels, watchful waiting, which dispenses with monitoring and recommends treatment only when symptoms appear, may be more appropriate than surveillance. Currentlytherearenorobustpublished studies thatcompareoutcomes foractive surveillancevs immediate treatment.But the panel highlighted the as-yet unpublished randomized controlled Prostate CancerInterventionVsObservationTrial, whichfoundnostatisticallysignificantdifferences in prostate cancer mortality or all-causemortalityafter10yearsbetween men who chose waiting and those who had radical prostatectomies. It isnow“reasonable”tosuggestactive surveillance for a certain group of men withprostatecancer,“butquitehonestly, this is a very young field,” said Ethan Basch,MD,MSc,associateattendingphysicianandoutcomesresearchscientist at Memorial Sloan Kettering Cancer CenterandimmediatepastchairoftheAmerican Society of Clinical Oncology guidelinescommittee. “The first stepwillbe to demonstratethatactivesurveillancedoes not cause harm, and then we have to refine which patients will benefit, how we do surveillance, and what the threshold is for treatment. Many people currently feelthethresholdistoolowinsomeactivesurveillance approaches.” Some answers will come from trials already in progress, but the panel stressed an immediate need to standardize follow-up protocols of active surveillance, which currently are variable and not evidence-based, to understand the outcomes of active monitoring. Citing biopsy problems with sampling error and misclassification of tumors, as well as pain, anxiety, and infection rates, the panel also called for alternatives to repeat biopsy “to reduce morbidity and to encourage compliance with active surveillance.” The panel also identified a number of priorities for research, including studies to improve physician communication about surveillance and decision-making support for patients. “If we do not offer surveillance as an option topatients,wewillbemissing the opportunity to provide a choice that,for manymen,willbeverysatisfyingandwill helpthemaccommodatetheirdiagnosis,” says Ganz. news@JAMA From JAMA’s Daily News Site